A limited thoracocervical approach for accessing

the anterior mediastinum in retrosternal goiters:

Surgical technique and implications for the
management of head and neck emergencies
| Reprints
March 16, 2016
by Petros V. Vlastarakos, MD, MSc, PhD, IDO-HNS(Eng); Aaron Trinidade, MD, PGDip, MRCS, DO-HNS; MarieClaire Jaberoo, MD, FRCS(ORL-HNS), DO-HNS; George Mochloulis, MD, CCST(ORL-HNS)

Abstract
In this article we describe the surgical management of retrosternal goiters via a limited
thoracocervical approach, and we explore how the respective surgical know-how can be used in the
management of the carotid blowout syndrome. Four cases involving patients who had undergone
thyroidectomy via a limited thoracocervical approach are retrospectively reviewed. An acute blowout
of the innominate artery managed with the same principal surgical technique is also reviewed. Three
patients had a total thyroidectomy and one had a hemithyroidectomy. No malignancy was found.
There was no mortality or unexpected morbidity from the limited thoracocervical approach. The
median length of the inpatient stay was 3 days. The blowout survivor lived for 9 months, with no
rebleeding and with an acceptable quality of life. We conclude that a limited thoracocervical
approach can be safely performed by head and neck surgeons for accessing the anterior
mediastinum in retrosternal goiters, and the respective surgical know-how can be used in the
immediate management of an acute carotid blowout syndrome with satisfying long-term results and
provision of quality end-of-life care.

Introduction
A retrosternal goiter is one that extends beyond the thoracic inlet. Although a precise definition is not
uniformly accepted among all authors, 1 the most commonly held concept is to consider a goiter
retrosternal when more than 50% of the total bulk of the thyroid tissue resides below the thoracic
inlet.2 The cumulative incidence of retrosternal goiter has been estimated to be 6.28% of all goiters. 3

Retrosternal goiters usually progress slowly and can remain asymptomatic for many years. When
symptomatic, they can cause compression to the trachea and esophagus (dyspnea, swallowing
difficulties) or, less commonly, to vascular and nervous structures (i.e., superior vena cava
syndrome, Horner syndrome, hoarseness, etc.). 4 There seems to be a consensus among surgeons
that such goiters should be removed even in the absence of clinical symptoms 5 because of their
tendency to resist medical treatment, the potential for a life-threatening emergency relating to the
goiter, and the non-negligible risk of malignancy.4,6-8
Thyroidectomy in the presence of retrosternal extension is performed via a cervical approach in
more than 70% of cases, 3 with the remaining goiters requiring some form of thoracic approach.
Although the presence of a thoracic/vascular surgeon may be required in some of the latter cases
(i.e., for a thoracotomy), a limited upper median sternotomy (manubriotomy) represents an excellent
alternative for gaining access to the anterior mediastinum. This approach has recently gained
popularity among head and neck surgeons.9-11 Furthermore, the indications for such an approach
can be expanded for the surgical exploration of the mediastinum in a range of indications. 10
The aim of this article is to present our experience in the surgical management of retrosternal goiters
that require a limited sternal split, and explore how the surgical know-how that results from this
approach can be used in the management of the carotid blowout syndrome, which represents one of
the most dramatic and life-threatening ENT emergencies.

Patients and methods

Patients with retrosternal goiter. A series of 4 patients who had undergone thyroidectomy with
sternal split at a single center by the senior coauthor (G.M.) between 2003 and 2011 were
retrospectively analyzed. Two of them were men and 2 were women. The mean age was 72 years
(range: 58 to 86).
All patients had a preoperative computed tomography (CT) scan of the neck and chest performed by
an experienced head and neck radiologist with hyperextension of the neck. All 4 patients were
determined to have a retrosternal goiter. A goiter was considered retrosternal and requiring a
thoracocervical approach when it extended below the level of the aortic arch on the CT scan. Three
of these patients had a total thyroidectomy and one had a hemithyroidectomy.
Patient with acute artery blowout. In addition to the 4 cases of retrosternal goiter, a case of an
acute blowout of the innominate artery, which was surgically managed by the same surgeon (G.M.)
through a cervicothoracic approach, was also retrospectively reviewed. The patient was a 41-yearold man who had undergone a total laryngectomy, a partial pharyngectomy, a bilateral neck
dissection, and postoperative irradiation for a T4 cancer of the larynx. The patient was being
regularly followed in the Head and Neck Outpatient Clinic for 2 years after his definitive treatment.

Unfortunately, this patient developed a stoma recurrence. After staging, the decision was made to
treat him surgically. He underwent excision of the stoma recurrence with radial forearm flap
reconstruction and made a full recovery. Four weeks after the surgery, the patient became unwell
and began hemorrhaging from the inferior aspect of the newly fashioned laryngectomy stoma. He
was examined by the senior ENT surgeon on call, who decided that immediate surgical intervention
was necessary.
After an anterior thoracocervical incision and sternal split were done, an acute blowout was found to
involve the innominate artery, proximal to the aortic arch and well within the thoracic inlet. An attempt
was made to repair the inmominate artery defect with the help of a vascular surgeon. Unfortunately,
because the wall of the artery was very fragile, the artery had to be ligated.
Surgical procedure. The basic steps of the surgical technique used in the present case series
include an anterior cervical incision, after which the neck strap muscles are divided to afford maximal
exposure of the cervical portion of the goiter. The chest wall incision starts from the suprasternal
notch and extends 6 cm. Blunt dissection of the undersurface of the manumbrium is achieved using
two fingers. A Richardson retractor is then passed retrosternally (figure 1). This provides protection
to the underlying mediastinal structures during splitting of the manubrium with a sternal saw (figure
1). A 4-cm incision is usually adequate but can be extended if necessary.

Figure 1. Intraoperative photo shows placement

of
the
Richardson
retractor
during
the
manubriotomy.

Once the manubrium is split, a Tuffier retractor is used to retract both halves of the divided
manubrium (figure 2). Once hemostasis has been achieved, parallel holes are drilled approximately
1 cm lateral to the cut edges of the sternum using a hand drill, and 1-mm sternal wires are threaded
through, facilitating sternal closure (figure 3).

Figure 2. The divided manubrium is stabilized

with a Tuffier retractor.

Figure 3. Sternal closure is achieved with 1-mm

sternal wires, threaded through parallel holes 1
cm lateral to the cut edges of the sternum.

The vertical extension of the cervical incision downward, toward the manubrium (limited upper
median sternotomy), has many advantages: It can be performed quickly, reliably, and with very low
morbidity by head and neck surgeons, providing excellent mediastinal exposure without
repositioning the patient.12,13 Moreover, the manubriotomy only minimally increases the average
hospital stay.14Indeed, 3 of the patients in our series stayed in the hospital for less than 4 days.

Results
Demographic data and information regarding the patients' diagnoses, procecdures, and length of
hospital stay are presented in the table.

Table. Demographic and general data of the case

series

Of the 3 patients who had a total thyroidectomy and the 1 patient who had a hemithyroidectomy,
none was found on histologic examination of the excised glands to have a malignancy. There was no
mortality or unexpected morbidity as a result of the surgery performed via a thoracocervical

approach; 1 patient experienced temporary postoperative hypocalcemia. The postoperative course

was uneventful in 3 patients, and additional surgery was required in 1 patient, although it was
unrelated to the preceding thyroidectomy. The median length of hospital stay was 3 days.
The patient who experienced the blowout of the innominate artery survived for 9 months after the
operation with an acceptable quality of life. He experienced no rebleeding and died as a result of
disease progression.

Discussion
Many study groups have attempted to define the factors that increase the likelihood of a sternotomy,
but a consensus does not yet exist. Huins et al proposed that an extension of the goiter below the
level of the aortic arch is an indication that the gland cannot be safely delivered via a cervical
approach alone.3 More recently, Cohen proposed that there are four factors that significantly
increase the need to perform a sternotomy: (1) the presence of malignancy, (2) involvement of the
posterior mediastinum, (3) the extension of the goiter below the aortic arch, and (4) the presence of
ectopic goiter.15 In our case series, we considered the goiters to be retrosternal if they extended
below the level of the aortic arch on the CT scan, which was performed by an experienced head and
neck radiologist with hyperextension of the patient's neck.
We also have presented in this series a case of surgical management of an acute blowout of the
innominate artery employing the same principal surgical technique. The carotid blowout syndrome is
a life-threatening end-stage complication of head and neck cancer with high neurologic morbidity
and mortality rates, occurring in as many as 4.3% of patients, 16 especially in the presence of
radiation-induced tissue necrosis, tumor recurrence, and pharyngocutaneous fistulas. 17
Although a number of reports in the literature advocate endovascular neuroradiologic intervention
(covered stents, coil embolization, detachable balloons, etc.) as the treatment of choice for the
management of the carotid blowout syndrome, 18-21 considering the surgical ligation of the vessel as
having unacceptably high morbidity and mortality,22 recent case series advocate a more skeptical
approach in readily and uniformly accepting this notion. 22 Although initial hemostasis may be
achieved with the use of neuroradiologic techniques, 23 the longer-term (so to speak) safety of the
patients, the patency of the stents (in reconstructive techniques), and the permanence of hemostasis
appear unfavorable.24,25
Nevertheless, the purpose of this report is not to deny the potential role of endovascular
neuroradiologic interventions in the management of carotid blowouts. In contrast, such interventions
may be successfully performed in a threatened or impending blowout setting. However, patient
selection should be made carefully, as patients with a life expectancy of more than 3 months seem
to fare worse after this approach than those who are closer to the inevitable outcome. 25 Our patient
survived for 9 months after his episode of acute blowout and passed away as a result of the

progression of his disease. No rebleeding occurred after the surgical management of his blowout,
nor did he encounter any postoperative neurologic morbidity.
We strongly believe that the surgical management of the carotid blowout syndrome is not an
obsolete treatment modality, especially in an acute setting, and that the trend of referring all these
cases for neuroradiologic endovascular interventions needs to be reevaluated in light of the relatively
long-term findings of the case series reported by Roh et al and Chang et al. 24,25

Conclusion
More than 2 decades ago, Nielsen et al suggested that the surgical treatment of patients with large
intrathoracic thyroid extension could be successfully performed in ENT Departments by surgeons
experienced in head and neck surgery.26 In light of the strenuous efforts of ENT surgeons to
establish ENT as the main head and neck specialty, and taking into account the advances in head
and neck surgery, this call seems more timely than ever. In addition, the hard-earned skills of head
and neck ENT teams for achieving access to the anterior mediastinum independently (in selected
cases) can also be used for the immediate management of the most devastating complication of
head and neck cancer-the acute carotid blowout-with satisfying long-term results. This provides the
patients under their care with a definite treatment without passing their end-stage management to
other medical specialties.

Acknowledgments
The authors would like to thank Mrs. Jackie Kiernan, Medical PA, for her invaluable help in retrieving
the patients' notes, and Ms. Megan Cope, from the Department of Clinical Photography and
Illustration at Lister Hospital, for providing the surgical photographs of patient 1.

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From the ENT Department, Lister Hospital, Stevenage, Hertfordshire, U.K.

Corresponding author: Petros V. Vlastarakos, ENT Department, Lister Hospital, Coreys Mill Lane,
Stevenage, Hertfordshire, UK SG1 4AB. Email: pevlast@hotmail.com